CQC report explained · a residential care home
What the CQC found at Delrose House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found enough staff, safe recruitment, suitable medicines arrangements and clear risk assessments.
- Effective?
- Good
- This area was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This area was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found an open, person-centred culture, clear management arrangements and systems for checking quality and making improvements.
What inspectors found, December 2023
Delrose House was rated Good; inspectors found people were safe and well supported, with minor building issues fixed during the visit.
This was a focused inspection on 15 November 2023. One inspector reviewed information from the service, spoke with people and staff, observed care, and checked records including care plans, risk assessments, medicines and staff files.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safe recruitment, suitable medicines systems, infection control measures and clear risk assessments. People said they felt safe, and staff understood how to report concerns.
The home had an open culture and an approachable manager. Audits, meetings and surveys were used to monitor care and make improvements. Two fire doors and some lifting flooring were identified as problems, but these were fixed on the day.
Enough suitable staff
There were enough staff to meet people's needs. Recruitment checks were completed, and the home did not use agency staff.
“There were enough staff to meet people's needs and to provide personalised care and support.” from the report
Safe medicines support
Inspectors found that medicines were administered by trained staff and records were complete. As-needed medicines had guidance explaining when they should be given.
“Medicine administration records were completed correctly and there were no missing signatures.” from the report
Open management
People and staff said the manager was approachable. The home used audits, meetings and surveys to monitor care and identify improvements.
“There was a positive and open culture at the service.” from the report
Personalised support
People received care that responded to their needs. Staff supported people to make day-to-day choices and worked with other professionals when needed.
“People received personalised care that was responsive to their needs.” from the report
Building repairs were needed
minorTwo fire doors did not close fully and some flooring was lifting. The report says these problems were fixed on the day of inspection.
“However, we noted 2 fire doors did not close fully against the frames, and the flooring in some places were lifting, these issues were brought to the attention of the registered manager and were resolved on the same day of the inspection.” from the report
- 01How do you check that the fire doors and flooring remain safe after the repairs identified during the inspection?
- 02How do you make sure there are always enough permanent staff who know each person's needs?
- 03How are medicines given when needed, and how do you check that the records remain complete?
- 04How are people and relatives asked for their views, and what recent changes have been made as a result?
- 05What were the previous ratings for Effective, Caring and Responsive, and when will these areas next be fully reviewed?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection published in 2018. This explanation was written from the published report of 13 December 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, February 2022
Inspected but not rated; inspectors found good COVID-19 infection control, but some flooring needed replacing and areas needed redecorating.
This was an announced, targeted inspection on 2 February 2022. Inspectors looked at infection prevention and control during the COVID-19 pandemic. They also asked about staffing pressures.
Inspectors were assured that the home was using PPE safely, arranging testing, managing outbreaks and supporting visits. Staff had updated PPE training, and there was a good supply of PPE and hand sanitiser.
The home had daily cleaning schedules, but some wooden flooring had gaps that made thorough cleaning difficult. Some areas also needed redecorating. The manager said the flooring would be replaced within four weeks.
The service was inspected but not rated. This report does not provide a full overall quality rating or ratings for all five areas of care.
COVID-19 planning
The home had policies and procedures for managing risks linked to the pandemic. The manager knew where to get advice about an outbreak and understood their responsibilities.
“The service had policies and procedures to manage any risks associated with the COVID-19 pandemic.” from the report
PPE and testing
There was a good supply of PPE and hand sanitiser. Staff had updated training, and regular COVID-19 testing was available for people, visitors and staff.
“There was a good stock of Personal Protective Equipment (PPE). Hand sanitiser was available in different areas within the service.” from the report
Family contact
People were supported to keep in touch with relatives, and visits were available at all times.
“People living in the service and their relatives were supported to maintain contact, with visiting available at all times.” from the report
Flooring needed repair
needs fixingSome wooden flooring had gaps, which made it difficult to clean thoroughly. The manager said it would be replaced within four weeks.
“However, we noted some of the wooden flooring had gaps in them which made it difficult to clean thoroughly.” from the report
Redecoration needed
minorInspectors found that some areas of the home needed redecorating.
“Some areas of the service also needed redecorating.” from the report
- 01Has the wooden flooring been replaced, as the manager said it would be within four weeks?
- 02Which areas needed redecorating, and has that work now been completed?
- 03What measures were in place to manage COVID-19-related staffing pressures?
- 04How are COVID-19 testing, PPE use and outbreak procedures being managed now?
- 05How are visits from relatives supported if there is an infection risk?
This was a targeted inspection of infection prevention and control and COVID-19-related staffing pressures; the service was inspected but not rated overall. This explanation was written from the published report of 16 February 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Delrose House
3 rated inspections over 8 years: the service has held its Good rating throughout.
- December 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2022Inspected but not ratedSafe: Inspected but not rated
- April 2018Goodstayed GoodSafe: GoodWell-led: Good
- July 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 6 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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